Presentation on theme: "Colitis in the Very Young. Case 8 month old presented with bloody bowel movements and diarrhea Maternal history of UC Endoscopy – pan colitis Infectious."— Presentation transcript:
Case 8 month old presented with bloody bowel movements and diarrhea Maternal history of UC Endoscopy – pan colitis Infectious w/u negative Started on Mesalamine Prednisone – 1 mg/kg
Persistent episodes bleeding Additional testing? Medical management?
Medical course – – Hypertension (3 drug) – Osteopenia – DVT – Persistent pancolitis Medical options?
Medical Therapy Medical treatment options? IV steroids? Infliximab? Tacrolimus? Fecal transplant?
Surgical Options? Optimization for surgery? IPAA candidate?
Clinical Course Age two - Total abdominal colectomy with plan for delayed reconstruction Persistent bleeding from rectum Completion proctectomy with J-pouch reconstruction Pouchitis responsive to antibiotics
Patient 2 – refractory UC 18 year old male – 3 weeks bloody diarrhea – 8 BM per day – Cultures and C. difficile negative Colonoscopy –pancolitis, normal ileum Placed on prednisone (60 mg daily) with improvement Mesalamine maintenance – 1600 mg bid Symptoms rapidly recurred as soon as prednisone tapered despite mesalamine – Prednisone dose increased
What would you do for maintenance therapy? Azathioprine or mercaptopurine Methotrexate Infliximab Adalimumab
One year remission rates in UC Thiopurine - Pediatric IBD registry 50%* Infliximab - ACT 1 clinical trial30%** Adalimumab - ULTRA 2 clinical trial22%*** Methotrexate - retrospective VA30%**** *Hyams AJ Gastro 2011 ** ACT 1 and 2 NEJM 2006 *** Sandborn, Gastroenterology 2012 ****Khan, IBD Journal 2012
Management Patient started on mercaptopurine Dose increased to 2 mg/kg/day – Still steroid dependent after 3 months – Level – 6TG 168, 6MMP – 4200 Infliximab and surgery discussed but reluctant – 6MP – 37.5 mg daily – Allopurinol, 100 mg daily After 2 months – 6TG 306, MMP 0, improvement but still requires low dose steroid (10-15 mg daily) 3-5 BM per day
Management 2 Repeat colonoscopy – active disease from transverse to rectum (Mayo score 1-2) Begun on infliximab Continued allopurinol / 6MP Improvement after 3 months – Steroid free – 2-3 BM per day
Questions Would you continue the mercaptopurine in addition to the infliximab? Would you continue the allopurinol? What about the risk of hepatosplenic T cell lymphoma? Is surgery preferable to all this immunosuppression? What information would surgeons give to help this patient weigh risks and benefits?
Outcome Allopurinol discontinued, but disease worsened Infliximab dose increased to 10 mg/kg every 6 weeks, but disease remained active Referred to a surgeon for information, but not interested in surgery Second opinion – Restart allopurinol, continue 6MP – Disease enters remission, continues combination therapy for UC
Presenting history 16 year old male Presented with bloody diarrhea EGD normal; colonoscopy with normal TI and pan-colitis Responded to IV steroids Flared during oral prednisone taper Received infliximab 5 mg/kg x 2 seven days apart Second opinion, admitted PUCAI 80, Cdiff negative
Diagnostic Tests CTE: pan-colitis, normal small bowel Flex Sig: severe colitis, CMV PCR negative Infliximab level 9 days after second 5 mg/kg dose: 18 mcg/mL, neg. antibodies
Medical Therapy Medical treatment options? IV steroids? Higher dose infliximab? Tacrolimus? Vedolizumab? Fecal transplant?
Clinical course IV steroids and infliximab 10 mg/kg x 2 seven days apart TPN PUCAI 75
Medical or Surgical Therapy? Tacrolimus? Vedolizumab? Diverting ileostomy? Subtotal colectomy with end ileostomy? Procto-colectomy with J-pouch and ileostomy?
Clinical course Subtotal colectomy with end ileostomy Colectomy specimen: no creeping fat, terminal ileum normal, severe chronic active colitis No granulomas or transmural inflammation Discharged home, feeling well Two months later developed mouth sores, otherwise feels well, with second stage J-pouch planned soon Tests?
Diagnostic Tests EGD: Antrum with apthous ulcers – mild chronic active gastritis and duodenitis Ileum: first 5 cm friable with chronic active ileitis, remainder normal Flex Sig: inflamed rectum with chronic active colitis
What Now? Does he have Crohns or UC ? Other tests ? Proceed with procto-colectomy with J-pouch and ileostomy? Treat proctitis and then proceed with ileo- rectal anastomosis if healed? Wait?